Notice of Mianyang Municipal People's Government on printing and distributing the measures for the implementation of Mianyang's basic medical insurance system for urban workers at the corresponding level

(Spontaneous recurrence [1998] 172)

In order to implement the State Council's decision on establishing the basic medical insurance system for urban workers, according to the Notice on Implementing the Basic Medical Insurance System for Urban Workers in Mianyang City, the implementation measures for the basic medical insurance system for employees at the corresponding level are formulated.

I. Tasks and Principles

1, the main task of the basic medical insurance system for urban workers is:

Establish a basic medical insurance system for urban workers, that is, a social medical insurance system that adapts to the socialist market economic system and guarantees the basic medical needs of employees according to the affordability of finance, enterprises and individuals.

2, the principle of establishing the basic medical insurance system for urban workers is:

The level of basic medical insurance should adapt to the development level of productive forces in the primary stage of socialism; All employers and their employees in cities and towns should participate in basic medical insurance and implement territorial management; The basic medical insurance premium is shared by both the employer and the employee, and the social pooling and individual account are combined.

Second, the scope of insurance and payment methods

1, all employers in Mianyang, including enterprises (state-owned enterprises, collective enterprises, foreign-invested enterprises and private enterprises), government agencies, institutions, social organizations, private non-enterprise units and their employees, must participate in the basic medical insurance (Fucheng District, Youxian District, municipal and above units participate in the basic medical insurance at the city level). Within the scope of the Ministry, provincial units, railways, electric power and other enterprises with high production mobility and their employees can participate in Mianyang's basic medical insurance at the corresponding level in a relatively centralized manner in accordance with the principle of territorial management, implement unified policies, and raise, use and manage insurance funds in a unified manner.

2, the basic medical insurance premiums paid by employers and employees.

The employer's contribution rate is 7% of the total wages of employees in the previous year, and the individual contribution rate of employees is 2% of their salary income in the previous year. With the development of economy, the contribution rates of employers and employees can be adjusted accordingly.

3. The total wages of employees in the previous year shall be subject to the statistical caliber of labor wages of the Municipal Bureau of Statistics. If the payment wage is lower than the city average wage, it shall be paid according to the city average wage.

4. The collection and payment of basic medical insurance premiums for employees can be entrusted to the bank for collection, or directly paid by the unit on a monthly or quarterly basis (before 10 day of the 65438th month of each month). Fails to pay or fails to pay, according to the late fee of 2‰, incorporated into the overall fund; If the overdue payment is over 3 months, the medical insurance relationship will be suspended.

5, retirees to participate in the basic medical insurance, individuals do not pay the basic medical insurance premium.

6, the insured unit division, merger, termination, must first pay off the unpaid medical insurance premiums; When an enterprise goes bankrupt and liquidates, it must pay off the unpaid and payable medical insurance premiums in full.

Three, the establishment of basic medical social insurance and personal accounts.

1. The basic medical insurance combines social pooling with individual accounts, and the basic medical insurance fund consists of pooling funds and individual accounts. Individual accounts and pooled funds are accounted for separately and cannot be squeezed out of each other.

① Personal account: all the basic medical insurance premiums paid by employees are included in personal account. The basic insurance premium paid by the employer is divided into two parts, one part is used to establish the overall fund, and the other part is included in the personal account.

The proportion included in the personal account is calculated according to the employee's salary (annual retirement fee for retirees), 3% under 45 years old (including 2% paid by individuals) and 4% over 45 years old (including 2% paid by individuals); 4% of the annual retirement fee for retirees is transferred from the social pooling fund to individual accounts.

Individual medical accounts are allocated quarterly according to the unit payment.

② Overall fund: the balance of medical insurance premiums paid by the unit after deducting them from personal accounts is used as the overall fund, which is managed by the Municipal Social Security Bureau.

2, personal accounts and overall fund payment scope:

(1) Personal account is mainly used to pay for outpatient medical expenses, and can also pay for the out-of-pocket part of hospitalization medical expenses. When the payment is insufficient, they will pay in full.

② The overall fund is mainly used to pay the hospitalization expenses. The hospitalization expenses of the insured (in line with the scope of basic medical reimbursement) shall be settled in a single hospitalization. Qifubiaozhun for each hospitalization pooling fund payment is: tertiary hospital 700 yuan, secondary hospital 600 yuan, primary hospital and ungraded hospital 500 yuan. The minimum threshold for retirees is lower than that for employees 100 yuan. Medical expenses below the minimum threshold can be paid by personal accounts or by individuals themselves. The basic medical insurance premium above the minimum threshold and below the maximum payment limit is mainly paid by the overall fund, with 80% of the employees (20% paid by individuals) and 90% of the retirees (individual payment 10%). The cumulative maximum payment limit of the annual basic medical expenses of the insured is 25,000 yuan.

(3) Medical expenses that meet the basic medical reimbursement after being transferred to a foreign public hospital for emergency on business. The minimum payment standard is employee 700 yuan and retiree 600 yuan. Those above the minimum payment standard and below the maximum payment limit are mainly paid by the overall fund, with employees accounting for 70% (individuals accounting for 30%) and retirees accounting for 80% (individuals accounting for 20%).

④ On-the-job and resident retirees in different places do not use medical magnetic cards. Outpatient medical expenses are used according to the above-mentioned Article ①, and hospitalization medical expenses are handled according to the above-mentioned Article ③.

3. The insured person needs long-term dependence on drugs for outpatient medical treatment and needs outpatient medical treatment after being discharged from hospital due to serious illness, and it meets the scope of basic medical reimbursement. There are hospitals and units above the second level that have been audited by the Municipal Social Security Bureau, and the personal burden ratio is 30%, the unit burden ratio is 30%, and the overall fund payment ratio is 40%, which is summarized by the unit every six months and reimbursed by the Municipal Social Security Bureau.

Four, the management and supervision of the basic medical insurance fund

1, the basic medical insurance fund shall be included in the financial special account management, which shall be used for special purposes and shall not be misappropriated.

2, the Municipal Social Security Bureau is responsible for the basic medical insurance fund raising, management and payment.

3, the Municipal Social Security Bureau shall not be extracted from the insurance fund, solved by the municipal budget.

4. Calculation method of the bank interest rate of the basic medical insurance fund: interest is calculated at the deposit interest rate for the part raised in the current year; The fund principal and interest carried forward from the previous year shall bear interest at the bank deposit rate of lump-sum deposit for 3 months; The deposited funds deposited in the social security financial special account shall bear interest at the three-year zero deposit and lump-sum savings deposit rate not lower than the interest rate of this grade.

5. The principal and interest of individual accounts are owned by employees and can only be used for medical expenses. Cash cannot be withdrawn or used for other purposes, but can be carried forward and inherited. When employees are transferred from this city, the balance of personal account funds will be transferred or returned to me at one time.

6. Settlement of basic medical expenses.

(1) settlement of medical expenses of insured persons

Outpatient medical treatment: all medical institutions and pharmacies that implement computer networking will use magnetic cards to settle accounts, and all personal accounts will be paid by themselves; Where the designated medical institutions and pharmacies that have not implemented computer networking purchase drugs, they will all be settled in cash, and then the municipal social security bureau will make monthly or quarterly unit settlement.

Hospitalization: If the insured employees really need hospitalization due to illness, they should go to the Municipal Social Security Bureau or the agency of the Municipal Social Security Bureau in the designated hospital for hospitalization with the admission certificate and letter of introduction from the unit. Where the designated medical institutions that have implemented computer networking are hospitalized, the hospitalization medical expenses shall be settled by magnetic card. The expenses below Qifubiaozhun, the personal conceit part and the self-paid part shall be directly charged to the patients by the medical institution according to the regulations. Part of the overall fund payment shall be settled by the medical institution and the Municipal Social Security Bureau. All patients hospitalized in designated medical institutions without computer networking will be settled in cash with medical institutions, and will be settled by the unit to the Municipal Social Security Bureau after discharge.

(2) the designated medical institutions and pharmacies to co-ordinate fund settlement.

The 25th of each month is the settlement date. The designated medical institutions that implement microcomputer networking will report the outpatient medical expenses and hospitalization expenses of discharged patients to the Municipal Social Security Bureau for settlement according to regulations, and the designated pharmacies that implement microcomputer networking will report the monthly drug purchase expenses of the insured to the Municipal Social Security Bureau for settlement according to regulations.

The time for submitting the fee settlement of designated medical institutions and pharmacies is within 10 days after each settlement date.

7, designated medical institutions, pharmacies in violation of the relevant provisions of the basic medical insurance, by the Municipal Social Security Bureau according to the seriousness of the case, informed, and impose an economic penalty of 3-5 times the illegal cost, if the circumstances are serious until the cancellation of designated qualification.

8, the insured units, the insured in violation of the relevant provisions of the basic medical insurance, by the Municipal Social Security Bureau according to the seriousness of the case, informed, and impose an economic penalty of 3-5 times the illegal cost, if the circumstances are serious until the freezing unit account and the insured magnetic card.

9. The Municipal Social Security Bureau shall, according to the basic medical service scope, standards, medical expense settlement methods, drug list, diagnosis and treatment items, medical service facilities standards and corresponding management measures formulated by the labor and social security department at a higher level, and in combination with the actual situation of our city, formulate corresponding measures in conjunction with relevant departments, and organize their implementation. Before the introduction of the above management measures, the drug list, medical service scope and standards shall be temporarily implemented according to the original measures.

10, the basic medical insurance is managed by designated medical institutions and designated pharmacies. The Municipal Social Security Bureau shall, jointly with the relevant departments, be responsible for determining the designated medical institutions and pharmacies according to the qualification examination methods for the designated medical institutions and pharmacies formulated by the labor and social security departments at higher levels, and sign medical service contracts with the designated medical institutions and pharmacies to clarify their respective responsibilities, rights and obligations.

1 1, the Municipal Finance Bureau should strengthen the supervision and management of the basic medical insurance fund.

12, the Municipal Audit Bureau shall regularly audit the income and expenditure and management of the medical insurance fund of the Municipal Social Security Bureau.

13, the municipal health bureau should conscientiously implement the "Decision on Health Reform and Development" of the Central Committee and the State Council (Zhong Fa [1997] No.3), actively promote the structural adjustment of the medical and health service system, accelerate the reform of health institutions, standardize medical behavior, reduce staff and increase efficiency, and improve the utilization efficiency of health resources. It is necessary to invest less money so that the people can get basic medical services and promote the healthy development of medical and health undertakings. It is necessary to gradually implement separate accounting and management of drugs in municipal medical institutions, form a competitive mechanism between medical services and drug circulation, and reasonably control the level of medical expenses. Actively develop community services and incorporate basic medical services in community services into basic medical insurance coverage.

14, the establishment of Mianyang basic medical insurance fund supervision group (participating units and personnel separately) attended by relevant government departments, employers, medical institutions, trade union representatives and relevant experts, whose main responsibilities are:

(1) is responsible for supervising and inspecting the implementation of the basic medical insurance policies and systems;

Responsible for the supervision and inspection of the collection and use of medical insurance funds;

(3) To be responsible for supervising and inspecting the implementation of basic medical policies, charging standards and service quality by designated medical institutions;

(4) Responsible for supervising and inspecting the implementation of basic medical policies, drug quality, price and service quality of designated pharmacies.

Five, properly solve the medical problems of relevant personnel.

1, the medical treatment of retirees and the old Red Army remains unchanged, and the medical expenses are solved according to the original funding channels. If it is really difficult to pay, the people's government will help solve it.

2. The medical treatment of disabled revolutionary servicemen above Grade B remains unchanged, and the medical expenses will be solved according to the original funding channels. Separate accounting management by the Municipal Social Security Bureau, and the insufficient medical expenses shall be solved by the Municipal People's Government.

3 national civil servants enjoy the Medicaid policy on the basis of participating in the basic medical insurance, which will be implemented after the state formulates specific measures.

4, in order not to reduce the existing medical consumption level of some employees in specific industries, on the basis of participating in basic medical insurance, as a transitional measure, it is allowed to establish supplementary medical insurance for enterprises. The part of enterprise supplementary medical insurance premium within 4% of total wages is paid from employee welfare funds, and the insufficient part of welfare funds is included in the cost after being approved by the Municipal Finance Bureau. Enterprise supplementary medical insurance is not included in social pooling. The delineation of specific industries will be determined after the state formulates relevant documents.

5. The basic medical insurance for laid-off workers of state-owned enterprises is still implemented according to the Notice on Medical Insurance for Employees of Bankrupt State-owned Enterprises during Custody (Mianfu Office Letter [1998] No.41).

6. The medical expenses incurred by employees of municipal administrative institutions due to work-related injuries and maternity are not included in the basic medical category, and the Municipal Social Security Bureau shall implement the work-related injury and maternity insurance system among employees of municipal administrative institutions.

7. The medical expenses above the maximum payment limit are still implemented according to the solution of special medical expenses for seriously ill workers with more than 25,000 yuan in documentNo.. Mianwei Office issued [1998]05, and the new regulations will be implemented after the country has them.

Sixth, strengthen organizational leadership.

The reform of medical system has a strong policy and involves a wide range, which is related to the vital interests of workers, economic development and social stability. All insured units should earnestly strengthen leadership, unify their thinking, raise awareness, do a good job in the propaganda and ideological work of employees, so that the broad masses of employees and all sectors of society actively support and participate in the municipal overall planning of the basic medical insurance for urban employees, and conscientiously organize the implementation of new and old programs in accordance with the tasks, principles and requirements for establishing the basic medical insurance system for urban employees. Combined with the actual situation of our own unit, we can ensure the smooth transition between the old and new schemes.

Seven. others

1, and the measures shall be implemented as of 1999 1. The original Measures for the Implementation of Mianyang Medical Security System Reform and the Detailed Rules for the Implementation of Mianyang Workers' Social Medical Insurance are inconsistent with these Measures.

2. The Mianyang Municipal Social Security Bureau shall be responsible for the interpretation of these Measures.